Universal health coverage – A must to reduce out-of-pocket expenditures and for better quality of life among the cancer patients

FACTORS CONTRIBUTING TO THE COSTS OF CANCER

As the authors rightly briefed in the manuscript, “Quality of Life, OOPEs, and Indirect Costs among Patients with Central Nervous System Tumors in Thailand”^[1] that the costs of illness can be divided into three categories:

1. Direct medical expenses, which are typically covered by national public insurance. However, some direct medical costs, such as clinic visits, other prescriptions, and alternative therapies, require patients to pay OOPEs.

2. Direct non-medical costs incurred by patients and family include costs for transportation, food, accommodation, home modification, nutrition supplements, and caregiver’s salary (OOP expenditures).

3. Indirect costs include expenditures for informal care (unpaid caregivers) and productivity loss. Indirect costs of cancer are just as significant and problematic for cancer patients and their families. As these are indirect costs, most of them are difficult to quantify and track. However, these costs are significant for cancer patients and families and add to the overall costs of cancer care.

There is no “one-size-fits-all” cancer treatment; therefore, the costs of cancer treatment vary significantly from patient to patient. However, there are several consistent factors that contribute to patients’ overall costs for their health maintenance which includes insurance status/type of insurance coverage, in-network versus out-of-network, balance billing, and unexpected costs; other factors contributing to costs and causing variation are as follows: treatment plan, geographic location, and treatment setting. In most countries, including those with national health insurance or comprehensive public insurance, some expenses for cancer treatment are borne by the ill and their families.

Conceptually, the economic burden of cancer can be divided into three categories: Psychosocial costs, indirect costs (mostly productivity losses), and direct costs, which further can be divided into medical and non-medical costs paid either by third-party payers (e.g., health-care systems or private insurers) or by patients out-of-pocket.^[2] Studies have extensively evaluated the direct medical costs associated with cancer that is paid by health-care systems. Cancer is associated with high OOPEs. Health-care systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to care.^[3]

UNIVERSAL HEALTH COVERAGE (UHC)

UHC means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.^[4]

Thailand established national universal coverage in 2002. All Thai citizens are covered under one of the three public insurance schemes, namely, the Civil Servant Medical Benefits Scheme, the Social Security Scheme, and the Universal Coverage Scheme.^[5]

However, in India, OOPEs account for about 62.6% of total health expenditure – one of the highest in the world. Lack of health insurance coverage and inadequate coverage is important reasons for high OOPEs. There are many public health insurance programs offered by the government that covers the cost of hospitalization for the people below poverty line, but their coverage is still not as desired.

Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched as a step toward UHC. The concept covers three key elements — access, quality, and financial protection. India is committed to achieving universal health care for all by 2030, which is fundamental to achieving the other sustainable development goals. PMJAY was a step in this direction providing insurance cover to the poorest 40% of the population. Over 50 crore Indians are covered under the scheme with an insurance cover of Rs. 5 lakhs/family. PMJAY provides comprehensive hospitalization cover for secondary and tertiary care.

PMJAY has scored over its predecessor – Rashtriya Swasthya Bima Yojana – on several measures. It covers a larger population, provides a more comprehensive benefits package, and has a wider hospital network for availing care. In terms of operations, it has superior IT and governance systems and is building state capacity in management and governance. Availability of portable benefits where eligible individuals can seek care anywhere in India is an example of this capacity.

However, the current state insurance schemes and tax-funded free or subsidized care interventions are unable to mitigate the burden of OOPE.^[6-8] The National Health Policy (2017) [9] of India aims to correct this and reduce the burden of OOPE (Sustainable Development Goal 3.8.2). It suggested an increase in public spending from 1% to 2.5–3% of GDP – as envisaged in the National Health Policy 2017 – can decrease the OOPE from 65% to 30% of overall health-care spend.

Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health-care services. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce OOPEs, insurance needs to cover all family members rather than restricting coverage to a specific defined maximum.

The Ministry of Health and Family Welfare released the National Health Accounts (NHA) estimates for India. The health accounts are a globally accepted tool to describe the flow of funds in a country’s health system in a financial year.^[10] Its estimates provide a snapshot of the flow of funds in the country’s health system by financing sources, providers of health care, and health-care functions. The most salient feature publicized by the ministry during the recent release of the NHA estimates is the rise in government contribution to the total health expenditure from 29% in 2013–14’ to 41% in 2017–18’, leading to a decline in household OOPEs from 64% to 49% in the same period.^[11] However, it was widely argued by the economists that the sharp decline in the share of OOPEs in total health expenditure in a single financial year (59% in 2016–17’ to 49% in 2017–18’ in NHA 2017–18’) is an error.^[12]

NHA 2017–18, released recently, brought mixed messages. It reports a decrease in OOPEs, but at low levels of overall spending on health and government health expenditure (as percentage of GDP). Reduction in OOPE signals that the financial burden caused by health-care expenditure is getting lighter. However, a much higher level of government financing is required for delivering needed health services to all citizens, with assured quality and minimal financial stress. As costs increase, a larger burden is being placed on patients and their families. The financial burden of cancer treatment has a toxic impact on many aspects of patients’ lives, including their financial well-being, health-related quality of life, and mortality.